Discussion and opinion from a large, academic anesthesia department

February 14, 2014

The current economic and legislative reality creates an imperative for leaders in academic medicine to develop a value equation — one that takes into account clinical outcomes and financial impact— for integrating their three missions: clinical care, education, and research. Even exceptionally skilled individual leaders will not be able to forge this future. Rather, improved performance requires diverse, well-coordinated teams capable of leveraging their differences and engaging in collaborative problem-solving and continuous learning.

In most academic medical departments, the three missions are led as silos. And with strong reason: “the cultural barriers to change in health care—doctors’ resistance to being measured, their need to be ’perfect,’ their reluctance to criticize colleagues, their resistance to teamwork—reflect a deep-seated belief that physician autonomy is critical to quality in health care.” Sharing stories about transcending these obstacles is critical.

February 02, 2014

His tattoo read "White Power" in 3-inch calligraphic letters. Emblazoned across his chest for all to see, the ink wasn't something I would normally have missed during my physical exam. In this case, though, his tattoo had been hidden by a bulky neck collar and the array of lines and tubes that come with being a comatose trauma patient.

Only on my third day of being this man's physician did I find myself confronted with the aggressive declaration.

I found myself wondering whether he would want me, a black woman, to be his doctor.

There was no dissatisfaction apparent in many interactions with his family, but they were somewhat distant. Was the distance born of shock over a relative's sudden, life-threatening injury? Or of discomfort with me?

As physicians, we take note of patients' demographics in part because it helps with diagnosis: Black patient with anemia? Think sickle cell. Greek patient with anemia? Think of the blood disorder thalassemia.

The Hippocratic Oath cautions us against refusing to treat patients based on these characteristics.

Doctors aren't supposed to be racist. We tend to think of ourselves not so much as people with specific identities, but more as disembodied brains and skilled hands ready to go about the work of healing.

My patient's tattoo was an unwelcome reminder that the skin I inhabit can't be checked at the hospital door.

Race is sometimes overtly discussed in health-care encounters, but usually because a patient expresses a preference for a clinician of a particular racial or ethnic background.

It is rarer for a patient to say that he or she does not want to be cared for by certain people. A few high-profile cases in the last several years involved white patients refusing care by black nurses.

While these requests are perhaps reprehensible, more controversial was the facilities' responses - in all the cases, the patients' wishes were honored. Some of the affected nurses successfully sued their employers for accommodating the racist requests, which had essentially allowed prejudice to affect their working conditions.

How should health-care providers respond to a racist, sexist, or bigoted patient? Sachin Jain is a physician of Indian descent who wrote about his experience with a patient who yelled at him to go back to India. Jain chose to yell back, a decision he later questioned.

In the New York Times' "Well" blog, Asian physician Pauline Chen revisits the Jain story and describes her own encounter with a combative swastika-decorated patient in the emergency room. She didn't wait for the patient to express his discomfort with her - she instead chose to remove herself from his presence as soon as it was clinically appropriate.

I explored the topic of racist patients in a piece for the Journal of the American Medical Association this month. I argued that I wholeheartedly reject racism and race-based prejudice, but I also recognize that patients have the right to choose their care providers and to have some control over the conditions of their care.

The therapeutic relationship between doctors and nurses and their patients is founded on mutual trust and respect; when these are missing, communication suffers and care plans fall apart. If I care for a patient who does not want me as a doctor, I have done that patient a disservice.

The responses I received to the JAMA piece were mixed. Many people thanked me for tackling a difficult issue for minority clinicians.

A few, though, criticized me for condoning inappropriate behavior. One person suggested that the clinical encounter could become a "teachable moment" in which I could fight prejudicial tendencies.

As much as I want to stamp out racism, I continue to believe that a one-on-one clinical encounter is the wrong venue to address this issue, for at least two reasons.

First, behavior is difficult to change. If I cannot persuade a patient to stop smoking or to eat more healthily, how will I convince them to shed long-held beliefs?

Second, asking for someone's respect when they are not inclined to give it is an exercise in futility. I learned that in high school.

I do think that there is a role for hospitals and other institutions to express that racism is not tolerated in clinical encounters. Similar to the "no smoking" signs that adorn healthcare facilities, I can imagine a "no offensive language or pre-judging" sign.

Health-care providers are under no obligation to treat patients in nonemergency situations, so perhaps instead of merely changing their clinicians, we should be referring bigoted patients to facilities willing to care for them.

That wouldn't have helped my trauma patient, though. He was at the brink of death, unable to declare his preference for care providers one way or the other.

As a result, he received superior care from people that he might have deemed inferior. Maybe the fact that we saved his life will serve as the ultimate teachable moment.

Meghan Lane-Fall is assistant professor of anesthesiology and critical care at the University of Pennsylvania. She can be reached atMeghan.LaneFall@uphs.upenn.edu

January 27, 2014

On Wednesday we accepted a transfer from a district hospital outside of Kigali. The patient was a 5 year old girl who had been hit by a car 2 weeks earlier. She suffered a skull fracture and CSF leak. With minimal surgical options at the district hospital, she was medically treated and kept in the hospital, intubated and in critical condition for almost 2 weeks. She was transferred to us after “deteriorating further”- high fevers, worsening mental status, etc.

She arrived to us intubated and completely unresponsive to even painful stimuli. A large pocket of pus could be felt under her skull and she was leaking CSF from her ear. It was clear that she was suffering from meningitis, and honestly I was shocked that she was even alive. With her being completely unresponsive, having no respiratory drive, and minimally reactive pupils, I pushed for palliative measures. We decided we would give her one more day on antibiotics and told her father that she would likely die that night.

I arrived at the ICU this morning expecting to find her bed empty. But I was shocked to find that she was improving! She was starting to follow commands and had improved respiratory function. She still has incredible obstacles to overcome if she stands a chance to survive this, but there is hope for her, especially now that she will have the opportunity for neurosurgical intervention.

Unfortunately, this patient is representative of a major problem in critical care in Africa- ineffective triage and failure to transfer patients to more capable hospitals before it’s too late. If we could improve the triage process of critical patients at the district hospital level, we could save many lives here.

I arrived in Kigali, Rwanda on September 30th, and am now two weeks into my two month assignment teaching critical care at the King Faisal Hospital. I am working for a program called Human Resources for Health, a project in Rwanda which falls under the umbrella of the Clinton Health Access Initiative. It is a 7 year program, currently in year 2, which recruits American faculty in medicine (all subspecialties), dentistry, nursing, and health policy/ hospital administration. Most faculty come for one year, although some plan to spend the entire 7 years in Rwanda. Depending on one’s length of assignment and specialty area, their focus may be on developing clinical policies to improve patient care, creating an entire residency curriculum (as was recently done for emergency medicine), or focusing on bedside teaching and resident education. As I am here for only 2 months, I have focused on resident education (anesthesia and internal medicine residents in the intensive care unit), the development of a critical care journal club for anesthesia residents at 2 different hospitals, and working to improve the daily schedule for faculty, residents, and medical students in the ICU.

King Faisal is a major referral hospital in Kigali, and accepts patients from across Rwanda, Congo, Burundi, and parts of Uganda. While technically a private hospital, it accepts the Rwandan national health insurance plan, and is thereby accessible to almost everyone (the national health insurance plan may cost as little as $6 per year, for those with very low income). The majority of patients treated in the ICU at King Faisal initially present to community clinics, where they are referred “up the chain” to a community hospital, district hospital, and finally to a referral hospital. This means that King Faisal’s resources are the best the country has to offer. They have a CT and MRI machine, 2 dialysis machines, a wide range of surgical capabilities, and an emergency department that is staffed 24 hours a day. While this may sound up to Western standards, in reality, it is far from it. There are no invasive monitors in the ICU, there is only one nephrologist (in the entire country), we routinely run out of even the most basic drugs, it takes approximately 12-24 hours to get lab results, the ABG machine is frequently broken and delivers unreliable results, etc.

Because there is no well organized system to identify and transport critically ill patients to the ICU in a timely fashion, patient’s often linger at the community or district hospital for long periods. This means that when they finally arrive at a referral hospital, their pathology is too advanced for our medical capabilities, and the mortality rate is very high. While the ICU does admit patients with diseases classic to sub-Saharan Africa (late stage AIDS, malaria), these are usually treated in the district level hospitals, and most of the patients in the ICU at King Faisal suffer from non-communicable diseases such as stroke, heart disease, or cancer. There is currently only one cardiologist in Kigali, one center in the country that can do basic chemotherapy, and 2 neurosurgeons in the country- who treat mostly head trauma from the incredible rate of motorbike accidents on the street. That being said, we do our best to treat who we can, with relatively little resources, and hope for the best.

In the next entry, I’ll detail what exactly I’ve been focusing my time on, and some of the major challenges I’ve identified to improving critical care services in Rwanda.

I walked into the ICU yesterday morning to find a crowd of people around a bedside, the “crash cart” close by. While not an unfamiliar scene for anyone who works in the ICU, the patient I found in the room was not exactly what I was expecting- a 14 day old baby with coarctation of the aorta- who was admitted to the ICU overnight in heart failure. The baby had just self extubated and her oxygen saturation was falling quickly. There were several attempts to intubate her by the pediatrician at the bedside, but they were unsuccessful and the baby’s heart rate dropped into the 50s, necessitating CPR and atropine. The only laryngoscope we had was too big for the baby, but we needed to make due with what we had. There was a properly sized laryngoscope in the NICU, but that was 2 floors away and someone was trying to find it.

We mask ventilated the baby with difficulty, and I looked into the airway. The previous ETT had been too big and there was considerable edema and erythema in the larynx. Unable to visualize the vocal cords (which is very unusual for a baby), I blindly placed a smaller ETT, which barely fit through the vocal cords. By luck, the ETT was in the right place and the heart rate improved with oxygenation.

The baby will live another day, but for how much longer? Coarctation of the aorta should be corrected immediately after diagnosis at birth. This baby was 14 days old and going into heart failure and pulmonary edema. With no surgical resources, I questioned at the time if I should have even attempted to reintubate the child, and in other situations I would have chosen not to. In this case, there is a pediatric cardiac surgery team coming to Rwanda in 3 weeks. If we can keep the child alive until then, maybe she can be operated on. Tick, tock.

In a recent speech to the AAMC meeting in Philadelphia, Pulitzer Prize winning author and columnist, Anna Quindlen, gave the following Gold Humanism Lecure. In the opening statement, she highlights the importance anesthesiologists can have with regard to patient engagement and satisfaction with care. We should all think about how we discuss options with patients.

Me and My Epidural BY Anna Quindlen

Some years ago I had some surgery at one of the best hospitals in the country. It was a revision of a surgery I’d had six months before, but I didn’t think much about that, although I had a few friends who were enraged about it, couldn’t understand how something could be done and then be undone so quickly. But I’d signed the release form in which I acknowledged that medicine is not an exact science, something I’d long understood, although I’d never gotten the impression that doctors did.

Same surgeon, same hospital, different anesthesiologists. The first two had been young women and these two were slightly older men and I tried not to let that matter. They tried the epidural once and it was no go. The second time only half of me got numb, although they acted slightly skeptical of my insistence that I could still feel my right leg.

“I think we should just go to a general anesthetic,” one said. “I think you should try again,” I replied. Afterwards, as he was leaving, he patted my finally numb leg and said, “Next time you’ll take the general.” And at that moment I came as close as I’ve ever come to saying the words that, spoken by an allegedly prominent person, seem to me to reflect that they’ve lost their mind, or lost their way. I almost said the words I’ve always promised myself I would never say, not to a ticket agent, a hotel clerk, a young reporter, anyone. I almost said: Do you know who I am?

The answer to that question, I realize now, is a very important one as as far as all of you are concerned today. Not, do you know I won a Pulitzer, or have been on the bestseller list, or give speeches like this one? But a more basic question: do you know anything about me? Do you know why I’m having an epidural rather than a general? Have you taken any time to familiarize yourself with my history in any way shape or form? Doubtless those doctors would have contended that they didn’t have the time, that there were many other cases for them to handle, that under the circumstances it didn’t matter. But that flew in the face of the behavior of the pair of anesthesiologists I had during my first surgery.

The young women sat down with me before we began, to explain the general anesthetic they though they were going to administer. I explained that I hated the idea of being unconscious, that I had chosen my surgeon in part because she was willing to operate with a local, that my doctor and I had discussed the use of an epidural extensively, and that I had brought along a CD player and an imaging CD especially designed for people undergoing surgery which I intended to use during the procedure. Which, by the way, I had heard about from my internist, who likes to play the east/west, mind/body angle a bit. Which is why she’s my internist.

“That’s all great!” said the more senior of the women. “You don’t really need a general anesthetic for this surgery, and I prefer to use the least intrusive kind of anesthetic if the patient is willing. And can I have the name of that CD? I’ve never heard of it.” Although she restrained my hands at the beginning of the surgery, 15 minutes in she released one so that I could scratch my nose, because it’s axiomatic that your nose is going to itch when your hands are restrained. “I can tell you’re not going to invade the sterile field,” she said.

Only a short interchange, yet in some fashion she knew who I was. And I assume she was at least as busy as her male colleagues.

October 04, 2010

Of particular interest is that the number of reports for wrong site surgery in Pennsylvania appear to be declining. However, wrong site placement of local anesthetic blocks is becoming an increasing percentage of the reports. For example wrong site blocks constituted 20% of the wrong site events in the first six months of data reporting to the PSA, but they accounted for 44% of wrong site events in the most recent six months of reporting. These are two of the four examples provided by the PSA: 1) a patient was scheduled for a surgical procedure on the left hand under axillary block. The anesthesiologist blocked the right arm. The correct arm, left, was marked appropriately. The error was discovered by the anesthesiologist after initiating the block. 2) A patient was admitted for surgery [on the right knee]. The patient was seen by the anesthesiologist who asked the patient which knee was to be operated on. The patient stated “left.” The anesthesiologist performed the nerve block on the left side. The patient was taken to the OR for the right-knee surgery where it was determined the nerve block was done on the wrong side. Doing a formal time-out before an anesthetic block could potentially eliminate about 27% (92 of 337) of the wrong site errors reported in the surgical suite. However, based on the data from the Preventing Wrong-Site Surgery Project, a time-out before an anesthetic block does not eliminate the need to do a time-out just before the start of the surgical procedure, with the site marking visible in the prepped and draped surgical field.

In the opinion of the PSA, the 2010 revision of the Joint Commission’s Universal Protocol does not help the confusion about when to do the time-out. The 2009 version states that the time-out should be done before the start of anesthesia; the 2010 version reverts to stating that the time-out should be done before the incision. Based on multiple studies from the Preventing Wrong-Site Surgery Project, the Authority strongly advises that a formal time-out be done with the anesthesia provider just before any anesthetic block is placed and that another time-out be done with the surgeon just before the incision, unless the surgeon performs the anesthetic block and incision in continuity after the surgical field has been prepped and draped.

August 05, 2010

The Agency for Healthcare Research and Quality has a section called case and commentary some of which are of interest to anesthesiologists. In October 2009 they presented a case that I briefly summarize as follows:

One day after a vascular bypass procedure on the right upper extremity that started under MAC but was converted to general endotracheal anesthesia, this 70 year old man complained that whenever “he tried to drink any liquid it would come right out his nose.”He promptly demonstrated this phenomenon when the surgical team expressed their skepticism.The patient took a gulp of orange juice with the physicians present and they witnessed that most of the juice came out of his nose and spilled onto his hospital gown;he demonstrated this a number of times showing its repeatability.Concerned about a pharyngeal fistula or some other anatomic abnormality the surgical team consulted an Otorhinolaryngologist who discovered a nasopharyngeal airway lodged within the nasal cavity (not visible externally) which apparently acted as a retrograde conduit of fluid.Chart review revealed that a nasopharyngeal airway had been used during the MAC portion of the patient’s surgery the previous day.The article notes that aspirated nasal airways have been associated with a number of complications including airway obstruction and that symptom may not present immediately.They noted one case in which an aspirated nasal airway was not discovered for weeks and was only discovered after investigation for persistent cough and recurrent chest infections (the device was lodged within the trachea near the right mainstem bronchus).The typical nasopharyngeal airway has no radio-opaque strip, RFID tag, or suture tail.Anesthesia devices are not typically “counted” so the only person who may know that a nasopharyngeal airway was used is the person who placed it.It would seem prudent to make sure that insertion and removal of nasopharyngeal airways are clearly noted on the anesthesia record, that the presence of nasopharyngeal airways are part of any “handoffs", and that changes in anesthetic plan are accompanied by a reevaluation of the need for any nasopharyngeal airways or other support devices that may have been placed.

Peter Pronovost’s very productive group examines a process by which previously unknown hazards that may be associated with the introduction of new health care services can be anticipated.The authors note that “One of the greatest challenges facing practitioners and risk managers is the identification of previously unknown hazards.These threats to patient safety often lie at the apex of available knowledge and are rarely – if ever – obvious.With the rapid proliferation of new health care services, unknown hazards may propagate as new therapies are integrated into the existing health care system.”They note that at present “a comprehensive approach by which to safely integrate new therapies into the existing clinical environment has yet to be clearly articulated.”The authors emphasize the need to engage in this process before the new therapy or process is instituted.They describe the use of a multidisciplinary team of the key stake holders involved with a given project.The framework they propose is “composed of five process phases: 1) identify existing knowledge of hazards and defenses (literature review, communication with other institutions), 2) anticipate what can go wrong (brainstorm concerns, failure mode analysis), 3) simulate the process, 4) analyze hazards and defects, and 5) design the system to defend against such hazards (develop an operational protocol and check list to standardize the management of patient cases and to serve as a safety check for use prior to every case, monitor any patient safety events).”Details of these steps are provided and three clinical examples of this process are given in the article.Ref: Herzer KR: A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.Jt Comm J Qual Patient Saf 2009;35:72-81

In a rodent study published in the June 2009 issue of Anesthesiology, Ren et al begins to separate the analgesic from the respiratory effects of narcotics.They found that administration of Ampakine CX717 attenuated (when given before) or reversed (when given after) an intraperiotoneal dose of fentanyl that would produce apnea.The authors note that the compound used is considered safe for primate studies and clinical trials for cognitive disorders.It also crosses the blood brain barrier.The effect of CX717 does not directly reverse the effect of the narcotic on the respiratory center but rather it accentuates a pathway that is important to generating the respiratory rhythm within the preBotzinger complex.Ren J et al: Ampakine CX717 protects against fentanyl-induced respiratory depression and lethal apnea in rats.Anesthesiology 2009;110:1364-70.

June 04, 2010

With 2,700 cases of wrong-site surgery continuing to occur annually, experts recommend more consistent adoption of the Universal Protocol (UP), or in this case, a defined alternative process when site-marking is impractical.

A recent review of the National Practitioner Data Bank and additional closed claims databases for wrong-site procedures estimated that wrong-site surgery continues to occur approximately 1,300 to 2,700 times annually in the United States, despite the Joint Commission (TJC) requirement for a UP five years ago. In addition, up to 30 percent of all wrong-site and wrong-patient procedures have their genesis before patient admission to the hospital from scenarios such as inaccurate clinic note dictations or mislabeling of radiographs, reinforcing the need for the UP to prevent error.

The UP was introduced by TJC in July 2004 as a National Patient Safety Goal and consists of three components: a pre-procedure verification process, surgical site marking, and a surgical "timeout" immediately prior to starting the procedure.

Expansion of "timeout" The timeout was recently expanded to include the verification of correct patient positioning, availability of relevant documents, diagnostic images, instruments and implants, and the need for preoperative antibiotics and other essential medications, e.g., the use of beta-blockers. Some disagree with an expanded approach, believing that it dilutes the original intent. However, many hospitals have found it to be helpful to improve all the processes of care.

Less widely publicized are wrong-site invasive procedures performed outside the operating room, highlighting the reason that this protocol should be applied equally to clinical settings outside the operating room for any invasive procedure that requires a patient's consent.

Improper surgical site-marking a common risk factorInadequate or inaccurate surgical site-marking represent a major risk factor for wrong-site surgery. Examples that have led to error include site-marking by a junior member of the surgical team who will not be present during the procedure, using an "X" that may be misunderstood as "not this side," the use of non-permanent markers that wash off during surgical prep, residual markings from previous surgery, or inability to mark the site (e.g., mucosal surfaces, teeth, visceral surgery).

Challenges with adoption of UPFive years after the launch of the UP, an editorial in the July 2009 issue of Patient Safety in Surgery reviewed the obstacles that have limited the effectiveness of UP and need to be addressed to improve the process. These include:

This article was reproduced with small modifications with permission from the Premier Safety Institute.Any reference to this article should link back to their site.

DSS comment:Reducing an event to zero is extraordinarily difficult as the medical profession is finding out.However, institutions and practitioners are also finding out that being involved in a wrong site event creates enormous negative publicity, regulatory scrutiny, fines and even loss of practice privileges.In addition to wrong sited surgery there exists examples of wrong sited nerve blocks, chest tube placement, and radiation therapy all of which place patients at risk.In the case of wrong sited blocks at minimum the patient must endure the discomfort of an additional procedure.On occasion there may be a complication from the wrongly placed block or the repeated block. It seems to me that before any procedure some sort of time out should occur to confirm the following: 1) the correct patient is being treated, 2) the correct supplies and drugs are available, and the 3) correct site has been identified.

May 28, 2010

Dr. Falk discusses what needs to be done when a patient unexpectedly does not “wake up” at the end of a general anesthetic: An unresponsive patient in the recovery suite should be approached as if they have a life threatening condition.Immediate evaluation and survey should include the basics of resuscitation.Can the patient maintain an airway? Are they respiring effectively?Are hemodynamic parameters adequate?If this initial survey is satisfactory further investigation to determine the cause of unconsciousness should be performed.Oxygenation should be immediately assessed with a pulse oximeter.A blood gas should be sent to determine ventilatory adequacy and for a quick determination of metabolic abnormalities (pH, PaCO2, glucose, hyper/hyponatremia, hypo/hypercalcemia).Other labwork should include a chemistry panel and a CBC.A thorough neurologic exam should be performed checking basic reflexes (pupil response and size, corneal, cough/gag reflex).In the absence of protective airway reflexes the patient should be intubated.If there is no suspicion of metabolic abnormalities or residual anesthetic drug, neurologic imaging and testing should be the next diagnostic step including CT scan and EEG.

Scott A Falk, M.D., is Assistant Professor of Anesthesiology and Critical Care, Department of Anesthesiology and Critical Care University of Pennsylvania, Philadelphia.He is also Medical Director of the Post Anesthesia Care Unit at the Hospital of the University of Pennsylvania

April 16, 2010

Dr. Wei expands on his conference comments concerning needle cricothyrotomy and jet ventilation after needle cricothyrotomy --The cannot ventilate/intubate emergency situation is responsible for a previously irreducible 1-28% of all deaths associated with anesthesia (Benumof and Scheller, Anesthesiology, 1989, 71:769-778). Needle cricothyrotomy followed by transtracheal jet ventilation (TTJV) or surgical cricothyrotomy are the recommended final life saving treatments in the “cannot ventilate/intubate” emergency by both the American Society of Anesthesiologists (ASA) and the Difficult Airway Society (Benumof et al., Anesthesiology 2003; 98: 1269-77, Henderson JJ et al., Anaesthesia 2004; 59: 675-94). Needle cricothyrotomy followed by TTJV is often an effective, quick, simple and inexpensive solution to the “cannot ventilate/intubate” problem, and should be available in every anesthetizing location (Benumof and Scheller, Anesthesiology, 1989, 71:769-778, attached). A commercial transtracheal jet catheter is recommended for needle cricothyrotomy as it will be less easily kinked compared to the regular #14 or #16 intravenous angiocatheter. A jet ventilator with high pressure oxygen source is recommended to perform effective TTJV after needle cricothyrotomy although the high flow but low pressure (15 liter/min) oxygen source from the anesthesia machine may provide partial oxygenation but not adequate ventilation. A needle cricothyrotomy connected to a conventional breathing circuit or Ambu bag may not be effective for adequate oxygenation and ventilation because of high resistance secondary to the small internal diameter (ID) of the needle (~ 2 mm) (Scrase and Woollard, Anaesthesia 2006, 61: 962-974). Complications of needle cricothyrotomy and TTJV include barotrauma (subcutaneous emphysema, pneumothorax and mediastinal emphysema), esophageal puncture, or bleeding (hematoma and hemoptysis). The barotrauma incidence during HFJV can be up to 10%. Strategies to prevent barotrauma during TTJV include following: 1) Obtain experience with TTJV by using it in elective cases or on a manikin before using it in the “cannot ventilate/intubate emergency” situation.Similarly get experience in placing a needle cricothyrotomy using manikins. 2) Make sure there is adequate exit for the volume of air being injected into the lung by observing chest movement and listening to breath sounds.In the situation of complete upper airway obstruction a second needle cricothyrotomy may be inserted as an expiration path. 3) Use low frequency (15-20 /min) and low driving pressure (starting at around 20 psi and increase gradually if needed). 4) A definite airway such as surgical airway should be established as soon as possible after successful needle cricothyrotomy.

Huafeng Wei, M.D., Ph.D. is Assistant Professor of Anesthesiology and Critical Care, University of Pennsylvania

April 07, 2010

Nundy et al examined the impact of a pre operative briefing on operating room delays and found that a pre operative briefing reduced unexpected delays by 31%.The authors developed a pre operative briefing tool that included the names and roles of the team members, the time out process, confirmation of antibiotics, a review of the critical steps in the procedure, and a review of the potential problems for the case.The review was done by the nurse, anesthesiologist and surgeon and took place just prior to the skin incision.Data was collected for two months prior to the introduction of the briefing protocol and this was compared to data collected for three months after the process was introduced (pre intervention and post intervention).The briefing process took about 2 minutes.Data on delays were collected using an OR briefing assessment tool completed by participants at the end of each operation.To the question “there was an unexpected delay related to the case”, during the pre intervention period 36% of the respondents agreed, while post intervention 25% of the respondents agreed; a reduction of 30%.To the question “communication breakdowns that lead to delays in starting a surgical procedure are common” pre intervention 80% agreed, while post intervention this was reduced to 65%.When examining the responses of surgeons reporting unexpected delays, the percentage decreased from 38% to 7% in the pre compared to the post intervention period.The authors suggested that a pre operative OR briefing process may improve OR efficiency by decreasing delays.They cited other work suggesting that a standardized communication process such as an OR briefing may also improve patient safety and outcome.Ref: Nundy S. et al: Impact of preoperative briefings on operating rooms delays.A preliminary report.Arch Surg 2008;143:1068 -1072.

March 11, 2010

Use the following hypothetical case as a starting point.A morbidly obese (BMI 48.8) woman in her early 20’s with no significant past medical history presented for relatively minor, superficial, elective surgery involving skin grafting.In the pre operative holding area her vital signs were normal except for a pulse of 142.An EKG showed sinus tachycardia.The patient notes significant anxiety.The patient is given 1 L crystalloid and 2 mg midazolam and her pulse came down to 128.The decision was made to proceed to the operating room and an uneventful induction of general endotracheal anesthesia ensued.After a second liter of fluid, the heart rate remained in the 130s and an intraoperative venous blood gas was sent.The results were remarkable for a pH of 7.25; a calculated bicarbonate of 14, and a glucose of 486.The pt was given a 10 unit IV insulin bolus and started on an insulin drip.She received an additional liter of IV fluid and was admitted for further evaluation of her hyperglycemia and acidosis.

Diabetic ketoacidosis (DKA) can present with signs and symptoms of excessive thirst, urination, vomiting, abdominal pain, confusion, tachypnea and tachycardia.However in some cases the symptoms can be minimal. DKA can also present in type II diabetics but is more common with type I diabetes.It is often precipitated by insulin omission or an underlying stress such as an infection or myocardial infarction.The diagnosis of DKA includes hyperglycemia (though often less than 600 mg/dL), acidosis, and the presence of ketone bodies in the blood or urine.DKA differs from hyperglycemic, hyperosmolar, nonketosis (HHNK) which more commonly presents in type II diabetics.Ketone bodies are rarely seen in HHNK and patients often have a glucose > 600 mg/dL.

Treatment and anesthetic concerns of DKA are focused primarily on the underlying fluid deficit and electrolyte abnormalities as well as treatment of the hyperglycemia.Patients in DKA can have a fluid deficit of 3-6 L and should be resuscitated with normal saline at a rate of at least 0.5 – 1 L/hr with the goal of replacing 1/3 of the deficit in the first 6-8 hrs and the remaining 2/3 over 24 hours.Depletion of total body potassium (often 3-5 mEq/kg) is the primary electrolyte disturbance and serum levels reach a nadir 2-4 hours after IV insulin therapy is started.Potassium repletion is necessary and should be monitored every 2-4 hours in the early treatment phase.An intravenous insulin bolus of 10 units followed by a continuous infusion is a standard practice.The degree of acidosis should be followed by an ABG or by following the anion gap.After the glucose falls below 250 mg/dL, the IV fluids should include 5% dextrose.Insulin should be continued until the ketosis resolves.

Ref: Miller R (ed): Miller’s Anesthesia, 2005

Dr. Duggan is a senior resident in the Department of Anesthesiology and Critical Care at the University of Pennsylvania

February 18, 2010

Lingard et al reports the results of a 13 month prospective study on the occurrence of “communication failures” in which data collected prior to an intervention was compared to data obtained post intervention.Communication failures were defined as situations in which communication occurred too late, had inaccurate content, failed to achieve its purpose or excluded relevant team members as observed by a trained 3rd party observer who was in the operating room during the case.The immediate consequence (if any) of each communication failure was also recorded from a list that included: inefficiency, increased team tension, resource waste, workaround, delay, patient inconvenience, and procedural error.The study took place at a Canadian academic tertiary care hospital and the study subjects were the OR teams made up of combinations from a pool of 11 general surgeons, 24 surgical trainees, 41 OR nurses, 28 anesthesiologists, and 24 anesthesia trainees.All general elective general surgery cases done during the study period were eligible and the patients were approached for consent at least 2 days before their scheduled surgery.There was a 5 month pre-intervention data collection period, a 3 month intervention implementation period (data not used) which was followed by a 5 month post intervention period of data collection.The intervention was the introduction of a self developed, validated checklist the completion of which was the focus of a pre-operative briefing led by the surgeon and attended by the nurses, anesthesiologists and trainees who would be participating in the case.The check list covered issues related to patient information such as the diagnosis, allergies, presence of key tests and consultation; and operative issues such at the operative plan, antibiotics, anticoagulants, anesthesia requirements, special instruments, etc. (see Lingard et al, 2005 for the details of the check list development and a copy of the check list).RESULTS: During the intervention and post intervention phases of the study 302 check list briefings were completed.Most briefings lasted 1 – 4 minutes.42% of the briefings took place prior to induction of anesthesia and 47% afterwards (for 11% the time of the briefing could not be determined).One hundred and seventy procedures were observed (86 pre-intervention and 86 post-intervention).The number of communication failures fell from 3.95 per procedure pre-intervention to 1.31 after the intervention (p<.001).The number of communication failures that were associated with at least 1 visible negative consequence fell by 64% (207 before introduction of the checklist briefing to 75 afterwards).In about 33% of the briefings the information exchanged led to the identification of a problem, a critical knowledge gap, led to a change in plan, or prompted a follow up action.A participant follow up led to the following observations: 92% agreed that the briefing allowed the team to identify and resolve problems, 88% agreed that it helped guard against mistakes and 62% agreed that the briefings were worthwhile overall.According to the authors the check list approach requires less training time than approaches such as crew resource management training and does not require the provision of significant non OR training time.The authors note that they encountered significant recurrent, cultural barriers to the implementation of their check list briefing.They note that all three OR professions (surgery, nursing, and anesthesia) are accustomed to thinking and working independently; they embrace the notion of individual excellence; and they are overwhelmed by chronic staff shortages, educational duties, and economic pressures.Each of these barriers threatens the consistent utilization of a new communication routine like the pre operative checklist guided briefing.For instance, team members may be reluctant to alter their habitual workflow to gather for a briefing, or they may resist the briefing because ‘if everyone knew what they were doing we wouldn’t have to do this,’ and they may necessarily prioritize other duties in their multitasking list. The authors cite Amalberti et al who wrote that historical and cultural precedents and beliefs that are linked to performance autonomy may pose the greatest threat to improved safety.

February 09, 2010

Philadelphia Inquirer January 26, 2010

Meaningful reform will require courage

By Valerie Arkoosh

Doctors can empathize with the president and Congress right now. Treating a relentless disease can be enormously frustrating, and sometimes we may feel tempted to give up and walk away. But just as doctors stay with their patients, Congress and the president must stay with their patient, the American public, by keeping their commitment to strong health-care reform.

Although the political world went topsy-turvy last week, the Massachusetts vote did not change a single thing for American patients. Close to 50 million remain uninsured, those with preexisting conditions still go uncovered, and many face delays and denials of care.

Over the past week, a number of prescriptions have been offered for the reform effort. Besides abandoning it entirely - which would be wrong for the reasons mentioned above - they include passage of only the least contentious reforms, in a compromise with Republicans; and House approval of the existing Senate bill, for which the support has been almost entirely Democratic.

Passing only the most popular parts of the bills would only create new problems. For example, if Congress requires insurance companies to cover all preexisting conditions but does not require that everyone purchase insurance, the commonsense response for most Americans would be to wait until they get sick to buy insurance. It would be like requiring car insurers to sell coverage at accident scenes; insurance premiums would skyrocket, and the insurance system would fail.

And if Congress does require everyone to purchase insurance, there must be provisions for those who can't afford it - pointing again to the need for a comprehensive bill.

The only sensible way forward is House approval of the Senate bill. The Senate and House bills have much in common: Both would eliminate the worst insurance-company abuses, create consumer-friendly insurance markets, help people afford insurance, change the way doctors and hospitals are paid to reward high-quality care, increase the number of primary-care doctors, and encourage preventative care.

The two bills differ in some important ways, including how we pay for reform and how much help low-income Americans will get. But these differences can be reconciled later through a process known as budget reconciliation, or in the three to four years before the legislation is fully implemented.

Despite all the talk during the past week of watered-down health-care reform, Americans will have to take a big step forward if they want to substantially improve the fairness and security of the system. It's up to the president and Congress to lead us in taking that step. Baby steps won't work.

At this critical moment, the president and Congress must not abandon the American people who elected them to solve this problem. They should move to pass the Senate bill and fix our failing health-care system.

Solving real problems, like curing tough diseases, is hard. Like doctors who muster the courage to prescribe a difficult but necessary treatment, our leaders must have the courage to put patients ahead of politics.

Dr. Valerie Arkoosh is a professor of clinical anesthesiology and critical care and of clinical obstetrics and gynecology at the University of Pennsylvania School of Medicine. She is also the president-elect of the National Physicians Alliance. She can be reached at valerie.arkoosh@npalliance.net

February 05, 2010

We have completed our last patient rounds, which included 16 dressing changes and 2 "mini- codes" on patients in distress that we were passing by. Everything went well, and our work here is coming to a close.

Dr. Maxie, the Haitian physician who is the chief of the hospital had kind words for us thus morning. He said "God brought you to us. You have been wonderful. You are now part of Haiti."

February 04, 2010

Today we can see that there is more room in the church, the location in which many of the trauma patients stay. Some patients with injuries too extensive for us to care for have been sent elsewhere as new additional resources became available. Others have gone home. Some remain to complete treatment, including starting rehabilitation for the loss of a limb. A few remain because they have nowhere else to go, as their home and possessions were destroyed

Today we saw one young man who cannot go home because there is not enough food at home for him to eat. Other members of the family have moved in and the family simply cannot afford to feed the people now living with them.

Tomorrow morning we have one last case to do in the operating room, as well as 16 dressing changes (3 with anesthesia). We will try to get all this done plus packed and ready to catch our bus to Port-Au-Prince at 11:30. We will spend the night in a tent city, and then return to the states leaving very early on Saturday morning. We don't know yet if we will make it home to Philadelphia on Saturday due to the weather there, but we will certainly try to get as close as possible.

One issue that can be a problem within any healthcare system is patient handoff and communication among team members. This is especially difficult if the physicians and nurses speak different languages, and the medical record is in French.

When we arrived there were no written notes for us to use. Patients had no name tags and X-rays were not marked by side (i.e. left vs. right). This, plus the lack of availability of providers to provide care, led to delays in wound dressing changes and little planning for future care.

Several changes in the process of patient care can now be seen. More X-rays have the side marked, patients now have ID tags, and we implemented a system of marking on the dressing or cast what the plan is as a guide future care. In addition, with the help of our PIH partners, the incoming medical team will receive a rather detailed spreadsheet listing critical healthcare information for each patient that we are caring for.

February 03, 2010

Oxygen is supplied throughout the hospital via tank. Because it is rather difficult to get heavy tanks to this fairly remote hospital in the mountains, they run the tanks dry before changing them. This does lead to rather fast tank changes in the middle of operations.

Things are a bit tired today, including the equipment. We have worn down the batteries, and did not have time between cases to get it charged. As a result, our team had to improvise and use the drill as a rather big wrench.

Another issue they struggle with are the drill bits. They have been used quite a lot, and as a result are becoming harder to use. However, overall supplies and equipment are very much up to the task at hand.

Today we continue to see patients arriving from Port-Au-Prince with un- or under- treated orthopedic injuries and wounds. The number of people living on the compound continues to grow. We were awakened this morning at daybreak (around 0500) by the sounds of many families engaged in the morning routine. This, of course, included barking dogs, roosters announcing their presence, and crying babies.

We are surrounded by life as well as suffering.

We continue to be aggressive in providing analgesia for dressing changes when necessary. In addition to the anesthesia provided in the wards, we are starting to bring patients into the OR to take down dressings following skin grafts. Many of these folks have been experiencing 3 weeks of pain on top of the earthquake. They have simply had enough, and do not tolerate painful procedures anymore.

Having said that, more often than not we are met with a smile, and they thank us even we return a fairly sedated child back to Mom's arms.

Moms here are very resilient. On our second day of surgery we later discovered that we operated on a mother's 2 children, 1 of which is an infant, at the same time.

Just to be consistent, we sedated her children this morning, one after the other, to take their dressings down. The good news is that both children are doing well. Yea.

Pulmonary embolus remains a common problem. It is difficult to get patients mobilized, and many have long bone fractures. SQ heparin is being administered when possible, but the limited availability of nurses makes this difficult at times. We have no way to confirm the diagnosis of a PE other than to rule out infection as a cause if increased RR and hypoxemia. Treatment options include IV heparin via minidrip and nasal oxygen.

Yesterday a Haitian physical therapist arrived and went right to work. He has limited supplies, but is working hard to get people up and about. Many, many people will need prosthetic care, and we have none.

In the meantime we are working on getting people up and about.This young lady is a fast learner.

February 02, 2010

This afternoon several groups of children of different ages are practicing outside. Our bet (not yet confirmed) is that this is the usual time for school- related music, and even though there are no teachers, the children are doing whatever parts of their normallives that they still can.

Today is turning into a day of change. We woke up to find about 1,500 people sleeping around the compound. Apparently the thousands fleeing Port- Au-Prince have made it to Cange. Since there is nowhere else to go, and the compound offers some security, sleep and food, they are now here.

As a result, we are receiving an influx of injured and sick.We saw several new patients now scheduled for surgery, and expect more as people are processed through the long line that is forming in front of the Emergency Room. We have a busy day already scheduled and expect things to get busier as the day goes on.

New issues for the hospital and our team come with the influx of so many people who need so much. The compound is making every effort to help, but there are no tents and people are sleeping on the ground in the open. Security is increasing, and we are taking appropriate measures for our own safety. However, we have so far had absolutely no problems with personal security. We hope to keep it that way.

Rounds today included a cardiac arrest. A patient admitted for heart failure decided to quit breathing while we were rounding. I am pleased to report that our chief orthopedic surgeon still knows how to do CPR. We were successful in establishing spontaneous pulse and respiration, but her future is uncertain.

In the operating room we have 9 cases scheduled so far. Five are major ortho cases, the rest are skin grafts to close wounds. Two if these cases are urgent add-ons, and we are prepared for more.

The little guy below is one of our success stories. The lucky children have a toy and a parent or other loved one with them.When resources exist, the family brings sheets from home for them to sleep on.

The children here are so good, considering what they have gone through. They have beautiful smiles and are very affectionate. Parents are caring and loving. Amazing people, really.

Our local physicians tell us that before the earthquake one of the major gifts to the community was a school run on the grounds. Unfortunately, many if the teachers were in Port au Prince at the time if the earthquake, and those that were here lost many lived ones. As a result, the school is closed with no ability to reopen anytime soon.

February 01, 2010

These guys work very hard. Since the wards are spread out, and thehospital is located on the side of a mountain, transport is by hand. These guys are patient and treat the patients with kindness. To date we have never waited for a patient to arrive. As long as the schedule is printed they follow it.

I am pleased to report that the rush to the OR is slowing. We are moving from major ortho cases to wound care.

Today we will do only 3 major ortho cases; the rest are wash outs and skin grafts.

Patients and staff are tired. They are 3 weeks into the earthquake and their injury. Many have undergone several operations. Each time they wake up they have lost (literally) another piece of themselves. Tears flow easily, and for good reason.

We are doing our best to use sedation as much as we safely can. In addition, we are working hard to get wounds clean enough to graft so that these folks do not have to return again to the OR.In addition to morning rounds, we conduct "wound rounds," during which one of our Anesthesiologists and Surgeons change dressing and tend to wounds. This allows us to plan wound care going forward and to provide sedation, especially for the children. Our Anesthesiologists are getting rather good at wound care.

Today's OR cases range in age from 2 to 36. While we have done older people, many people here are young, and we have been told the average life expentancy is 52 years.

We intended to have a short day today and do only those cases that had to be done. The OR is not usually open on the weekends. However, the local team stuck by us as we operated late into the evening on Saturday, and joined us on rounds as they have every day this morning at 0630.

We were followed by a film team documenting care provided through PIH.

They filmed rounds, wound rounds, as well as 1 case in the OR. It is a bit different to do a case while being filmed, but things for the most part went well. Unfortunately, 1 15-year-old child cried through a cast change, and in retrospect I should have sedated her. The kids here have been through a lot, and cry through any procedure even when no pain is involved ( as was the case here).

I doubt I was much more effective comforting a Hatian child in English than Tom was with the Haitian dogs!

We were met with flooded ORs when the doors were unlocked. We were able to save most of the equipment and supplies, and all the electrical equipment worked after drying out a bit.

We finished today's cases around 1 PM, and the team is looking forward to some down time today. We have a full day of cases Monday, and have scheduled cases through Friday as we try to complete surgical care on as many people as we can.

A new team from Duke will arrive sometime on Friday, which will be our last day of operating. We learned yesterday that we will return on Saturday.

Yes, Tom Floyd is a real man. Today we are doing a case that requires good muscle relaxation, which is not commonly used here. While they have ventilators on the anesthesia machine, it uses too much oxygen, which is supplied by tank and is in short supply. Therefore, when used, assisted ventillation is by hand.

The local team does not use neuromuscular monitoring, a skill we are introducing to them. In this photo, Tom Floyd is demonstrating what a normal response is on himself. He then compared normal to the patient after vecuronium.

I am waiting to hear the yelp when they try this on themselves...

The local staff are exhausted. In spite of this, and even after working late last night, their team returned early thus morning to do a full day's worth of cases on a day off. The physicians joined us for rounds at 6:30, and are helping with anesthesia and scrubbed in learning from our physicians.

This includes all the support staff, including folks to clean and sterilize equipment between cases.

Today for the first time we found empty beds and open floor space while rounding. The inflow of earthquake trauma patients is slowing down.We are starting to see an influx of patients with a wide variety of advanced disease presenting for care.

One such patient is a young boy who appears to have advanced osteosarcoma. He has a very large lesion on his lower leg with a large solid node in his groin. We will do a biopsy tomorrow, but the outcome is poor in any country if he has the advanced disease we fear he has.

While empty beds are hopefully a good sign, thus is not always the case. This was the bed for the boy who fell off the horse. He died last night at 9 PM with his mother and our nurses nearby.

January 29, 2010

We are having a rather busy day today. Our OR schedule was disrupted when this young man arrived in the morning. He fell from a gourde and became unresponsive. It appears that he has an epidural hematoma, although we do not have access to anything other than plan film X-Ray.

We took him to the OR to do an emergent Burr hole, but the procedure was not done when we were unable to find a neurosurgeon who was available to care for him. As a result, he us receiving medical management only.

He has only his mother at his side. He lost his father in the earthquake. Mom spent all she had to bury her husband and has nothing left. We will look into how much she needs to bury her son and do what we can to help.

We will now need to operate into the evening to allow us to keep up with need. Our OR schedule is full through Monday, and we are now booking into Tuesday. We are starting to schedule all procedures we expect any individual patient will need, so that definitive care is completed on as many patients as possible.

This afternoon "wound rounds" took almost 3 hours. We use a fair amount of ketamine for the children, as many have open wounds. We are learning how to do anesthesia on the floor, literally. Today we had to move from the cast room to the floor by a plug because the extension cord died in the middle of removing a cast in a child. Once the old cast was off we moved back to the cast room.

We are now well into our third day of surgery.We have 12 big cases and several small cases scheduled. We are trying not to do too many cases, but the local hospital is now asking us to take care of more and more people.

That hospital has stayed at 200% normal patient count, and they are admitting 10-15 patients a day as more people leave Port au Prince.Many are trauma patients who require surgical care.

We cared for a 12-year-old girl with a femur fracture. As she was waking up from her procedure she was calling for her momma, a term recognizable in most any language.

January 28, 2010

Today we have scheduled 12 cases, but the cases we do change as the day progresses due to new patients as well as changes in priority.

We are caring for several people who have undergone amputations who then became infected before they could undergo final wound closure. As a result we are revising lots of these wounds. We will then bring them back for washouts until clean enough to close.

The first case was a young girl with open wounds on her legs and arms. We are hopeful she will not loose a limb, but she will need skin grafts when the wounds are ready.

The CRNA I am working with is intermittantly tearful, and has been all morning. Caring for the girl was hard for her. I don't know what family members she lost, and language barriers and work environment prevent me from talking about this. However, her courage in coming to work to continue to care for these folks is amazing.

Today we gave the anesthesia team some more if the supplies we brought. They are very grateful for the gifts provided by Penn. Thank you for allowing us to provide these supplies.

We are integrating our supplies with the existing supply chain with rare exception. This is appropriate, especially given that we are the only team here operating.

Patient flow is much improved now that we know each other. It has been fun working towards integrating our team into this hospital. I would like to think that while the beer helps, ultimately it is the skill of our surgeons that did the trick. That, plus their obvious compassion and efforts to treat everyone with respect.

Regards

Michael

DSS: I made minor edits for spelling, and a minor change in some of the wording.

Good morning from the steps of the Friendship House. While waking up thus morning we were met by beautiful Africian music coming from the church.Not a bad way to start the day.

We finished up yesterday a little before midnight. However, Derick and Bab had to return to tend to a patient with some post- op bleeding.

We did 13 cases yesterday, including several children. Two were ASA 4, and several more were 3's. One was on a dopamine infusion (no pump) in the ward for pressure support.

Today we are working on our pacing skills, and have established a schedule we hope to follow for the remaining of our stay. Patient rounds at 0630, resupply at 0730, breakfast at 0800, team meeting at 0820, operations start at 0930, lunch- dinner at 1430, more operating in the afternoon, finish OR cases by 1900. We will work in a couple of hours of wound rounds in the afternoon.

January 27, 2010

No view boxes in the OR, so Xrays hang from the ceiling. The ortho docs are making do with no fluro, of course, and by all measures are doing a great job. The case they are doing now may allow the young woman to keep her leg.

All patients we are operating on who are not in the building the ORs are located in are transported to the building, leading to patients everywhere.

We are running 2 rooms. The 2 ortho docs are doing their thing in one room, while we have a rather full general surgery schedule in the other. The patient below is our third case. She is a very ill young woman undergoing a cholycystectomy. Tom, 1 of our 2 Anesthesiologists, was recruited to assist. As a result, I am doing anesthesia in both rooms with the wonderful help of the local team.

Good morning. We had an uneventful evening. We were able to spend some time with our hosts, assisted by Prestege Beer. Between sips we put together today's OR schedule.

We posted 10 cases, 1 of which was transfered to Port au Prince last night. Cases range from a hernia repair in a 2-year-old, lots of orthopedic cases, ending with an open cholycystectomy in a pregnant HIV positive patient.

In addition, our team will try to assist with dressing changes as much as possible. These folks are not able to receive analgesia-anesthesia before these procedures, and we hope to help with this.

Our hosts are incredible. The PIH staff include volunteers who are medical students and residents. They are bright and work very hard. They made great effort to get us integrated into the flow of things, something they have to do very often as teams come and go.

The local staff are also working very hard. They continue to impress us with the efforts they are making to help us help them.

In the OR we are running 2 rooms. We will be working with an anesthesiologist from Cuba, as well as CRNA students. They actually run a CRNA school here.Of course, there us the problem of not beingable to say anything to them, since neither Tom or I speak Spanish or French. Lots of hand waving.

The ORs are small but functional. The anesthesia machines have Sevi and Forane. They were very happy we brought LMAs, which they prefer to use. They reuse an LMA until it wears out.Intubation is less desired.

They seem interested in regional but do not seem to use it much. We will I troduce it to them today, as we plan on a fem pop block for the pregnant lady.

We have identified 41 cases to do and have not yet seen everyone. In addition they admit new folks daily through a small ER. I think the pace will be steady but not crushing until we leave.

January 26, 2010

There is a church located by the hospital. It has been changed into a surgical ward and today has 55 patients. The patients are tended to by a PIH physician who is a med - peds resident. He was here at the time of the earthquake and had to quickly learn how to care for patients with orthopedic injuries.

About half the patients are children, about half of which have family with them. Injuries range from open fractures to spinal cord injuries.

Post-operative deaths have mainly been due to PEA cardiac arrest, presumably due to pulmonary embolus. They are using SQ heparin, which is very hard when 2 nurses are caring for 50 patients.

So far every single Hatian we have met - patient or staff - has lost at least 1 family member in the earthquake.

We probably will have around 10- 15 cases to do tomorrow, plus a number of wound dressing changes we will do with anesthesia.Ten cases will be ortho, about 5 general.

PENN MEDICINE has established a mission in Haiti.Working though the organization Partners in Health (PIH) an organization that has a strong, ongoing presence in that country, the first team from PENN MEDICINE is already in Haiti.Members of the Department of Anesthesiology and Critical Care are part of that team which consists of orthopedic surgeons, trauma surgeons, intensivists, and nurses with experience in critical care, post anesthesia care, and operating room care.The Team Leader, Michael Ashburn, M.D., MPH, Professor of Anesthesiology and Critical Care, sent us the following e-mail dated January 25, 2010, 20:36

Folks:

We are now safe and sound in Port au Prince. We are in a secure tent city. There is water here, and we ate well on the plane. We gave our remaining food away to Haitians and elected to survive on Power bars until we reach the hospital sometime tomorrow.

The drive in from the airport was interesting. Only a few lights were on due to limited power (mainly from generators). People were out everywhere on the streets as they are afraid to sleep in their homes. Some food vendors were out, especially near the airport. There is tight security near the UN headquarters which is now beside the airport.

Devastation is everywhere. While some buildings are standing, every block has damaged houses, some are just piles of rubble.

The Haitian people we have met are very grateful and are gentle, polite people. I find this amazing considering the state of life they find themselves in.

All of our gear is still with us. We will sleep with the important gear, and get up early to make sure another team is not tempted.No worries; the drugs are under the watchful eyes of the ladies and the ortho supplies are guarded by the ortho docs. They now snarl at anyone who walks by their tent. Ha!

There are teams from several other institutions here; most of them are working in the city. They report improving supplies, but increasing frustration over poor collaboration between groups as well as critical needs such as no working autoclave in the Port au Prince major hospital. They say that they still have several hundred patients with ortho injuries, such as open fractures, waiting for surgery.

The ride to the hospital where we will work is expected to take 4 hours due to the road conditions.We do not have a departure time but are hopeful it will be fairly early to allow us to start working tomorrow and to avoid travel in the heat of the day.

Until tomorrow,

Michael

DSS:I made a few light edits – added some verbs to convert phrases to sentences and clarified some of the abbreviations; otherwise this e-mail is as Dr. Ashburn sent it.

January 21, 2010

This is a very difficult paper to present because of the complex data analysis but the findings are very interesting.This work suggests that even complex behavioral interactions can be examined.Basically the authors had trained observers record predefined elements of team behavior during 293 general surgery operations at 2 medical centers and 2 ambulatory surgery centers affiliated with the Kaiser Foundation Health Plan.After discharge, a medical record review for 30 day postsurgical outcomes was performed by a trained reviewer who did not know the results of the OR observations.The markers of team behavior used were as follows: Briefing – situation/relevant background is shared including patient name, procedure, site/side, plans are stated, questions are asked, and ongoing monitoring and communication is encouraged.Information sharing – Information is shared, intentions are stated, mutual respect is evident, social conversations are appropriate.Inquiry – Members of the team ask for input and other relevant information.Vigilance and awareness – Tasks are prioritized, attention is focused, patient/equipment monitoring is maintained, tunnel vision is avoided, and red flags are identified.The observers scored the surgical teams on a zero to four scale (never observed to frequently observed) during induction of anesthesia, intraoperatively and at handoff to the post operative care givers.The ratings were used to create a univariate behavioral marker called the Behavioral Marker Risk Index (BMRI) with values ranging from 0 to 1.A BMRI of zero represented good team behavior and 1 represented poor team behavior.

The authors found that the patients in this study were mostly middle aged with low to intermediate risk based on the ASA and the American College of Cardiology/American Heart Association classifications.Only four patients were ASA 4 and none were ASA 5.More than half (54%) of the procedures had “no complications” as the outcome rating but 24% had one or more post operative indicators of potential harm, 16 % had a minor complication, and 4% had a major complication.Three patients in the last group had an outcome of death or disability.In about 25% of the patients the BMRI was more than 0.50 indicating a high proportion of operative phases with infrequent observations of good team behavior.After significant data manipulation the authors found a strong association between teamwork behaviors and death or a major complication; specifically when teamwork behaviors were relatively infrequent the patient was more likely to experience death or a major complication.Clearly a study of this complexity has limitations as acknowledged by the authors.First, it is observational and does not provide mechanism.Second, it does not allow a determination of which behaviors, at which times during the procedure would be the most beneficial with respect to minimizing complications or death.Mazzocco K et al: Surgical team behaviors and patient outcomes.Am J Surg 2009;197:678-685

January 07, 2010

Wald et al reported a retrospective cohort study of 35,904 Medicare patients from 2,965 United States acute care hospitals who underwent major surgery (coronary artery bypass and other open cardiac operations, vascular surgery, general abdominal colorectal surgery, hip or knee joint arthroplasty) during 2001.Eighty six percent of patients undergoing these major operations had perioperative indwelling urinary catheters.Of these, 50% had their catheters for longer than 2 days post operatively.Those patients with catheters for more than 2 days were twice as likely to a develop urinary tract infection than patients with catheterization of 2 days or less.In addition post operative catheterization greater than 2 days was also associated with increased 30 day mortality, and decreased likelihood to be discharged home.In their introduction the authors note that the risk of urinary tract infection is 5 to 10% per catheter day beyond the first 48 hours.In their discussion the authors note that “among patients with urinary tract infection an estimated 3.6% will develop bacteremia – a condition that adds significantly to length of stay, and is a risk factor for death among elderly patients.”Wald HL et al: Indwelling urinary catheter use in the postoperative period.Analysis of the National Surgical Infection Prevention Project Data.Arch Surg 2008;143:551-557

December 04, 2009

A team of investigators from PENN MED (including WA Kofke, Department of Anesthesiology and Critical Care) recently investigated the effect of sustained fever (temperature greater than 38.3 deg C despite antipyretics) on the lactate/pyruvate ratio (LPR) of microdialisate samples obtained from brain tissue of patients who had acute subarachnoid hemorrhage (SAH).An increase in the LPR is considered a marker for increased anaerobic glycolysis, a sign of metabolic stress in brain.The authors defined an episode of metabolic crisis as an LPR greater than 40.Reducing body temperature with ice packs and an external cooling device reduced the mean LPR and reduced the percentage of LPR values in the metabolic crisis range.This was true whether or not ICP was elevated.The authors concluded that fever control is associated with reduced cerebral metabolic distress in patients with SAH irrespective of ICP (Oddo M et al: Induced normothermia attenuates cerebral metabolic distress in patients with aneurismal subarachnoid hemorrhage and refractory fever.Stroke 2009;40:1913-1916).

November 24, 2009

A team of investigators led by Roderic Eckenhoff recently published their identification of a fluorescent anesthetic compound that should assist in obtaining more precise information about the mechanism of anesthetics and allow more rapid testing of potential new anesthetic drugs.The compound, 1-aminoanthracene, is anesthetic, potentiates GABAergic transmission, and gives the appropriate dissociation constant for binding to the general anesthetic site of horse spleen apoferritin.Its signal intensity changes as it is displaced from this binding site so it can serve as a marker for site binding competition.The introductory three paragraphs of their paper provide a focused review of the structural requirements of an anesthetic site of action.Figure 8 is of particular interest in that it may be one of the first showing the distribution of a general anesthetic molecule within the brain.Ref: Butts CA et al: Identification of a fluorescent general anesthetic, 1-aminoanthracene.Proc Nat Acad Sci 2009;106:6501-6501

October 06, 2009

This preliminary study was published in New England Journal of Medicine (Haynes AB et al: A surgical safety check list to reduce morbidity and mortality in a global population. 2009;360:491-9, January 29).The primary result was that the introduction of a 19 item surgical safety check list reduced death from 1.5% to 0.8% (a 47% reduction) and inpatient complications from 11% to 7% (a 36% reduction).Specifically there were statistically significant reductions in surgical site infection, unplanned return to the operating room, death and “any” complication.Pneumonia was not statistically significant.The study was conducted in eight hospitals selected for a diversity of economic circumstances and patient populations.The authors prospectively collected data on 3733 consecutive patients before the introduction of the check list and then on 3955 consecutive patients after the introduction of the check list.The primary end point was rate of complications including death within the first 30 days after surgery.Enrolled subjects had to be greater than 16 years of age.Patients undergoing cardiac surgery were excluded.

The check list contained the following elements:

Sign in – Before induction of anesthesia, members of the team (at minimum the nurse and an anesthesia professional) orally confirm that:

1)The patient has verified his or her identity, the surgical site and procedure, and consent.

2)The surgical site is marked or site marking is not applicable

3)Anesthesia safety check is completed

4)The pulse oximeter is on the patient and functioning

5)All members of the team are aware of whether the patient has a known allergy

6)The patient’s airway and risk of aspiration have been evaluated and appropriate equipment and assistance are available.

7)If there is a risk of blood loss of at least 500 ml (or 7 ml/kg of body weight in children) appropriate access and fluids are available.Appropriate access is defined at two peripheral intravenous catheters or a central line placed prior to incision

Time out – Before skin incision the entire team (nurses, anesthesia professionals, surgeons and any others participating in the care of the patient) orally:

1)Confirms that all team members have been introduced by name and role

4)Confirms that prophylactic antibiotics have been administered less than 60 minutes before incision is made or that antibiotics are not indicated

5)Confirms that all essential imaging results for the correct patient are displayed in the operating room

Sign out – Before the patient leaves the operating room:

1)The nurse reviews the following items aloud with the team (name of the procedure as recorded; that the needle, sponge and instrument counts are complete or not applicable; that the specimen, if any, is correctly labeled, including the patient’s name; and whether there are any issues with equipment that need to be addressed)

2)The surgeon, nurse, and anesthesia professional review aloud the key concerns for recovery and care of the patient.

Check list training:All participants underwent training in the use of the check list prior to its introduction.This included lectures, written materials or direct guidance.

Complications examined:The complications sought were the ones used in the American College of Surgeons’ national Surgical Quality Improvement Program: acute renal failure, bleeding requiring the transfusion of 4 or more units of red cells within the first 72 hours after surgery, cardiac arrest requiring cardiopulmonary resuscitation, coma of 24 hours duration or more, deep-vein thrombosis, myocardial infarction, unplanned intubation, ventilator use for 48 hours or more, pneumonia, pulmonary embolism, stroke, major disruption of the wound, infection of the surgical site, sepsis, septic shock, the systemic inflammatory response syndrome, unplanned returned to the operating room, vascular graft failure, and death.Urinary tract infection was not considered a major complication.

Developing and adapting the WHO check list:WHO recognized that local situations may require adaption of the check list.They provide the following guidelines: the checklist should be concise, it should take no more than a minute to complete each of the three sections, each item on the checklist must be linked to a specific unambiguous action, it should be a verbal exercise, it should be collaborative, and it should be integrated with existing processes.

WHO Goals for the surgical check list:

1)The team will operate on the correct patient at the correct site.

2)The team will use methods known to prevent harm from anesthetic administration, while protecting the patient from pain.

3)The team will recognize and effectively prepare for life-threatening loss of airway or respiratory function

4)The team will recognize and effectively prepare for risk of high blood loss

5)The team will avoid inducing any allergic or adverse drug reaction known to be a significant risk for the patient

6)The team will consistently use methods known to minimize risk of surgical site infection

7)The team will prevent inadvertent retention of instruments or sponges in surgical wounds

8)The team will secure and accurately identify all surgical specimens

9)The team will effectively communicate and exchange critical patient information for the safe conduct of the operation

10)Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results.

Comments:In a June, 2008 press release (7 months before publication of this paper) the American Society of Anesthesiologists supported the WHO initiative for the “safe surgery check list”. A number of letters to the editor appeared in the May 28, 2009 issue of the New England Journal on the article.As might be expected the article created wide spread international media interest.In the “perspectives” section of The Lancet (February 14, 2009) Jeremy Laurance (health editor of The Independent, a British newspaper) commented favorably on the results as discussed by the senior author, Atul Gawande, when he gave the James Reason Inaugural Annual Lecture at London’s Royal Society of Medicine.However, Time Magazine (January 14, 2009) quotes concerns raised by Peter Pronovost who has done seminal work on the role of check lists in improving ICU outcome.Dr. Pronovost noted that covering every item on the check list after its introduction was not high (54%).He was also concerned that the decrease in complications and improved outcomes seemed too large for the interventions described.Others have wondered why the follow-up period was so short and whether or not the reported improvements were sustained.I find it interesting that the New England Journal published it as a “special article” and not as an “original article.” Finally the article describes decreased complications and death after the introduction of a check list, however it does not show how the check list as a whole or which particular parts of the check list may have had this effect.This article should be viewed as a start to an approach that may be of use in improving surgical outcomes, and not as the definitive statement on this important issue.This article, along with others, suggests that check lists should be taken seriously and not just as a chore to be dispensed with as quickly as possible.

NOTES

Blogmaster

This blog is organized and maintained by David S. Smith, M.D., Ph.D. Associate Professor of Anesthesiology and Critical Care, University of Pennsylvania. His subspeciality is anesthesia for patients undergoing neurosurgery. For the past 6 years he has had responsibilites for patient safety and clinical care quality improvment in a Department of over 65 faculty who provide anesthesia care for about 24,000 patients each year. Correspondance can be sent to upennanesthesiology@gmail.com

Mission Statement

The purpose of this blog is primarily to provide ongoing contact with former residents and faculty of the Department of Anesthesiology and Critical Care at the University of Pennsylvania, Philadelphia, PA, U.S.A. Others may also have an interest in the topics presented. We plan to discuss a variety of issues related to the practice of anesthesiology with an emphasis on patient safety, risk management and medical legal aspects of care.

Disclaimer

The content and observations on this Weblog come mostly from members of the Department of Anesthesiology and Critical Care of the University of Pennsylvania. However this material does not represent the official opinion of that Department, the University of Pennsylvania or any of its other Departments or Divisions. Medicine is a rapidly changing field. We cannot guarantee that any of the material here is correct or up to date.